Key Points

• There is an ongoing outbreak of extensively drug-resistant (XDR) typhoid fever in Pakistan. Extensively drug-resistant infections do not respond to most antibiotics.
• XDR typhoid infections in people with a history of travel to Pakistan have been reported in North America (United States and Canada), Europe (United Kingdom and Denmark), and Australia.
• All travelers to Pakistan are at risk of getting XDR typhoid fever. Those visiting friends or relatives are at a greater risk than tourists or business travelers.
• If you are going to South Asia, including Pakistan, protect yourself against typhoid infection by getting a typhoid fever vaccination, and take extra care to follow safe food and water guidelines.

What is the current situation?

Health officials in Pakistan have reported an ongoing outbreak of extensively drug-resistant (XDR) typhoid fever that began in Hyderabad in November 2016. The strain of Salmonella Typhi does not respond to most antibiotics used to treat typhoid fever. The outbreak has spread to provinces throughout the country, and several deaths have been reported. XDR typhoid associated with travel to Pakistan has been reported in the United States, Canada, the United Kingdom, Denmark, and Australia.

Public health authorities in Pakistan are identifying possible typhoid fever cases, starting typhoid vaccination campaigns in the most affected areas, and spreading educational messages about proper handwashing and safe food and water practices.

In the United States, public health officials have increased efforts to quickly interview and test samples from patients with suspected typhoid fever.

What can travelers do to prevent typhoid fever?

Get the typhoid vaccine

The CDC recommends that all travelers (even short-term travelers) to South Asia, including Pakistan, be vaccinated against typhoid fever before travel. Two typhoid fever vaccines are available in the United States—an oral vaccine and an injectable vaccine. Travelers should take one or the other. The oral vaccine, approved for people 6 years old or older, should be taken as directed, at least 1 week before departure. The injectable vaccine is approved for people 2 years old or older; travelers should receive the injectable vaccine at least 2 weeks before departure. Neither vaccine is 100% effective, so travelers should also practice safe eating and drinking.

Practice safe eating and drinking habits

Because the bacteria that cause typhoid fever are spread through contaminated food and water, you can reduce your risk of infection in several ways:

• Follow safe food and water guidelines.
• Wash your hands often, especially before eating.
• Avoid eating food prepared by anyone who is sick or has recently been sick.

If you get sick during or after travel

If you travel abroad and get sick while traveling, seek medical care. If you get sick after returning to the United States, seek medical care and tell your health care provider where and when you traveled. Do not prepare food for other people. Learn more about typhoid fever, how to prevent it, and what to do if you think you have it at CDC’s typhoid fever page for travelers.

Information for Health Care Professionals

The XDR strain of Salmonella Typhi is resistant to most antibiotics (ampicillin, chloramphenicol, trimethoprim-sulfamethoxazole, ciprofloxacin, and ceftriaxone) used to treat typhoid fever. Health care providers should:

• Obtain a complete travel history (asking about travel to South Asia, including Pakistan) from patients with suspected typhoid fever.
• Collect stool and blood cultures from patients with suspected typhoid fever and request antimicrobial susceptibility testing on isolates.
• Be aware that the Pakistan outbreak strain remains susceptible to azithromycin and carbapenems:
  • Azithromycin is effective for uncomplicated (diarrhea or bacteremia without secondary complications) typhoid fever and should be used to treat patients with suspected uncomplicated typhoid fever who have traveled to Pakistan. When culture and sensitivity results are available, adjust treatment accordingly. Adult azithromycin dosage is usually 1,000 mg orally once, then 500 mg orally daily; OR 1,000 mg orally once daily for at least 5 days. Pediatric azithromycin dose is 20 mg/kg orally once, then 10–20 mg/kg orally once per day (maximum 1,000 mg per day) for at least 5–7 days.
• Carbapenems should be used for patients with suspected severe or complicated typhoid fever who have traveled to Pakistan. Severe or complicated typhoid fever could include for example, gastrointestinal complications (such as typhoid-related intestinal perforation, peritonitis, intestinal hemorrhage, hepatitis), neurologic complications (such as typhoid encephalopathy, including altered consciousness, delirium, confusion), or bacteremia with sepsis or shock. When culture and sensitivity results are available, adjust treatment accordingly. Consider getting an infectious diseases consultation for these patients.
• Be aware that relapses can occur, often 1–3 weeks after clinical improvement.
• Be aware that most (90%) Salmonella Typhi isolates from patients coming from South Asia have decreased susceptibility or resistance to fluoroquinolones, including ciprofloxacin; therefore, fluoroquinolones should not be used as empiric treatment for suspected typhoid fever in patients who have traveled to this area.
• Report all cases of confirmed typhoid fever to the appropriate local or state health departments. Clinical laboratories should also submit all Salmonella Typhi isolates to their state or local public health laboratory for submission to the Centers for Disease Control and Prevention.

Traveler Information

• CDC typhoid website
• Vaccine Information Statement
• Food and Water Safety
• Visiting Friends or Relatives in a Foreign Country

Clinician Information

• Typhoid & Paratyphoid Fever in CDC Health Information for International Travel (“Yellow Book”)
• Information for Healthcare Professionals
• Typhoid vaccine recommendations of the Advisory Committee on Immunization Practices (MMWR 2015)